High-Cost Patients Benefit From Care Coordination

This population needs more attention, experts say

WASHINGTON -- Being in a Medicaid HMO may be quite complicated for some patients, what with figuring out which physicians and pharmacies will take your insurance. Now imagine being in three of them -- all at once -- plus a Medicare fee-for-service plan.

That's what many "dual eligible" patients -- low-income seniors who are eligible for both Medicare and Medicaid -- must deal with because their care isn't better coordinated, Katherine Hayes, JD, director of health policy at the Bipartisan Policy Center, said Monday at a briefing here on high-need, high-cost patients sponsored by the Alliance for Health Reform and the Commonwealth Fund. "In some states, dual eligibles [are enrolled in] Medicare fee-for-service and in three Medicaid managed care plans -- one for healthcare, one for behavioral care, and one for long-term care services," she explained.

But dual eligibles are only a subset of these high-need, high-cost patients, noted Karen Davis, PhD, professor of health policy and management at Johns Hopkins University in Baltimore. "They are not synonymous with dual eligibles -- [many are] not covered by Medicare and that's the subgroup that's hardest hit," she said. "They are also spending an extraordinary percentage out of pocket on medical and long-term care services."

These patients also are at very high risk for nursing home placement, Davis continued. "On average, it takes about 5 years before somebody with Alzheimer's winds up in a nursing home ... If you could delay that by even 9 months, you could save $112 billion in nursing home expenditures over 14 years."

Overall, approximately one in 20 U.S. adults qualify as high-need, high-cost patients, according to Melinda Abrams, vice president for delivery system reform at the Commonwealth Fund in New York City. "They are more likely to be older, to have low income, have public insurance, and use a lot of healthcare services," Abrams said. "They have higher out-of-pocket costs and more unmet needs."

These patients are also more likely to say it's difficult to get access to a medical specialist, but on the brighter side, these patients are also more likely to report having a patient-centered medical home, Abrams noted.

High-need, high-cost patients benefit from monitoring and from care coordination over time, and there are programs aimed at providing those services -- but there are barriers to increasing their scale, said Abrams. "First, there is the misalignment of financial incentives."

For example, there are accountable care organizations (ACOs) and Medicare Advantage plans that are receiving payments based on the value of care -- rather than volume -- which would tend to favor services like care coordination. However, even though the plans might be receiving such payments, "we're not necessarily seeing that value-based payment is the same thing as value-based compensation," she said. "It's not necessarily being felt on the front lines of care."

Healthcare groups are working on solutions, according to Abrams. One such effort is the Five-Foundation Collaborative. "Our five foundations will work together to improve our nation's capabilities in [three areas]: clarifying the needs of high-need, high-cost patients, elucidating the best ways of caring for them, and assisting with the spread of proven approaches," wrote David Blumenthal, MD, president of the Commonwealth Fund, and colleagues from the other four foundations in a New England Journal of Medicine Perspective article about the project.

One idea being looked at is a "Medicare Help at Home" program which would cover home- and community-based care under Medicare. Such a program, as discussed by Davis and a colleague in Health Affairs, could be financed by an additional $42 per month Medicare premium payment and an 0.4% increase in the payroll tax paid by employers and employees.

"This would enable organizations willing to integrate medical and long-term care services to begin to take financial accountability for an entire range of services," Davis said. Such organizations would be called integrated care organizations; they could begin as ACOs and would be able to share in savings for reduced and delayed nursing home placement, and they would develop individualized care plans based on patients' preferences.

Peter Boling, MD, chair of geriatric medicine at Virginia Commonwealth University (VCU) in Richmond, said that although he had thought that VCU's health system was doing a great job at providing safety-net care to the area's low-income patients, once he started making house calls "I found out that the patients I was seeing at home were not able to access healthcare in any regular way. They were having a terrible experience of care and landing in the emergency department and the hospital unnecessarily."

In addition, "There were poor interactions between office-based medical professionals and home-based agencies, and patients and families were really desperate for help," he said.

So VCU established a house-call program in which patients too sick to go to a clinic are given their primary care at home. "We look at them thoroughly and see them as often as they need to be seen," said Boling.

To be done well, a home care program requires a team that includes a social worker and a triage nurse, "and someone to analyze and track data and outcomes to make sure you're delivering the goods," he said. Eligibility requirements for patients include a hospitalization in the past 12 months, two or more serious health problems, and two or more deficits in performing activities of daily living.

Boling estimated that about 2 million patients nationwide would qualify for such a program. "We're trying to figure out how to do this in [a] fee-for-service [environment] and how to construct a mechanism using shared savings."

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